This Angel is pissed off. I'm Nurse Anne and I work on large general medical ward in the NHS. These are the wards with the most issues surrounding nursing care. The problems are mostly down to intentional understaffing by hospital chiefs that result in a lack of real nurses on the wards.
"The martyr sacrifices themselves entirely in vain. Or rather not in vain, for they merely make the selfish more selfish, the lazy more lazy and the narrow more narrow"-Florence Nightengale

Friday, 1 May 2009

Nellie's Shift

Nellie volunteered herself to do an extra shift on her day off.

There was only one nurse for the ward that day and that is dire. Beth was to be that nurse and she was freaking out about it. Nellie said that she would come in and work the day shift.

It was chaos. Thank god Nellie came in. A childminder may be able to set a limit on the number of people she looks after but a nurse cannot. A childminder cannot have additional children dumped on her with no warning, on top of her other charges. But we do this to nurses and expect them to function every day. Otherwise, they would have to close much needed beds.

Nellie and Beth had a crap day. Half the patients were acute medicals with massive amounts of stuff going on. The workload was unreal. The other half of the patients were 100% dependent elderly patients.

I would feel safer leaving my 9 year old unattended on a ward than my 98 year old grandmother. My 9 year old can follow directions, ensure his own safe environment to a point, ask questions, communicate, remember instructions etc. He will not throw himself on the floor, or try and eat his own faeces. He will not forget that he has a broken leg and try and walk to the toilet. I am not being disrespectful to people with dementia. I am explaining to you the facts of their condition and why they need so much care, rather than an overwhelmed nurse who cannot be there.

Your average person will go on and on about how they cannot help grandma in hospital. But if it was his or her 9 year old child, their arse would be parked on that ward 24/7. Visiting hours. On my ward we will let you stay as long as you behave. But no one wants to stay with grandma. They don't have the time. If it was their 9 year old child hospitalised they would find the time and not leave his side. Yes but it is the nurses who do not care. Right.

Nellie and Beth had a patient go into cardiac arrest mid morning before they even finished the 0800 tablets. It was a bad one. I am so glad I wasn't there. I would have freaked the fuck out. Cardiac arrests are the norm on medical wards. But when it catches you unexpected its like someone sticking their fist into your stomach and pulling all over your guts out and stamping on them. I cannot describe how I feel in those situations any better than that.

At 11:00 hours Beth needed to go in and talk with the now dead patient's family. This left Nellie on the ward. Alone. By 11:30 she had got through 5 of the 13 patients that still needed their 0800 meds. She was focused. She was rushing and nearly made a massive medication error but luckily she re-checked and she caught it. She became even more focused. Medication errors kill thousands of people in hospitals every year. Many (some say most) of these errors are caused due to the nurse being interrupted and or overloaded. It's a big problem.

There are mountains and mountains of individual drug charts each with many different medications prescribed on them and every single thing on those charts needs intense scrutiny. It took her until after lunch but she sorted the mess out. And it was a big mess. There was a lot of other things going on as well that only a nurse could deal with. She could hear the weeping and wailing from the family room, and knew that Beth wasn't having a good morning either. Only 3 HCA's were trying to hold down the fort basic care wise. They managed to bedbath and wash every patient who needed it. There were 15 patients such as this who need at least 15-20 minutes each if you are going to do a half ass job. Before they moved onto their next patient the previous ones were crying out again. That it. Two nurses (one with a grieving family) and 3 care assistants with a whole entire ward of patients who are more dangerous on their own than a young child.

A few weeks later our manager received a complaint to respond to. The reason for the complaint occurred on the day and the time of Nellie's extra shift. It went like this.

"I visited your ward on such and such a date around 11:30. I was appalled to see the condition of the patients. Call lights were not being answered. There was a lady who did not have any shoes on and she was sitting out in her chair. Her bed was unmade. Nursing care has really gone downhill. The nurse was in the middle of the ward staring at a trolley, oblivious as to what was going on and did not appear to care anyway. Her name was Nellie Doe. I looked at her name tag. I believe that if matrons came back to hospitals nurses like this would be dealt with."

True story. It's really not funny. This is getting beyond a fucking joke.

Thanks for coming in on your day off and working your tits off Nellie. I doubt you'll be suckered into it ever again.

Fact is, this is the kind of bullshit that the complaints department has to wade through on a daily basis.

I have a friend who works on a medical telemetry floor. The nurse's station is in the middle of the ward and their are monitors all over this station, displaying patient cardiac rhythms. That is telemetry. The patient wears a device that sends a reading to these monitors at the nurse's station. These monitors need constant monitoring. Sometimes you have a few patients to on telemetry and a staff member to just sit and watch the monitors. Some times most patients are on telemetry and you have no one to watch the monitors. Leads need to be printed etc. A missed assessment will kill on there.

My friend who works in telemetry reported that they are always getting complaints from visitors about "the nurse's sitting at the station watching TV's. Why do the nurses need those TV's? Why can't they look after the patients instead?"

Documentation and Computerised charting is essential, ESSENTIAL to patient safety whether we like it or not and there is a hell of a lot if it that needs to be dealt with for all your patients, during the course of the shift.

"Why are all the nurses playing on the computer rather than looking after the patients".

Yes, this is the kind of bullshit that the complaints department has to deal with. No wonder the real complaints don't get deal with properly.

When the person in charge is on duty (the ward manager) he is the primary nurse for 12+ patients as well, completely overwhelmed on his own drug round etc. Management stuff gets done as in his own time unpaid as much as possible. He does double shifts all the time to avoid staff nurses having to work as the only staff nurse. He's killing himself.

He is fighting for more staff, resources, and equipment. All the time. And he shopped the place to the unions etc.

The powers that be are supposedly hiring and putting this plan into action and that plan into action. They keep promising it will get better and the unions back off. In some ways it is better, and in some ways it gets worse.

I think things are looking up after staffordshire blew up. Suddenly there were jobs advertised for actual real live Nurses. I am hearing similiar things from other hospitals in the area so..............

We don't have as many beds as the others and sometimes are patients are no where near as acute.

We love our ward manager, and we always work our arses off because we want to do our best for him. He goes way above and beyond the call of duty. Some of the ward managers on other wards do not inspire their staff in this way. We feel the same way about our assistant ward nurse manager person.

If the shit hits they will scapegoat them.

What I am describing on this blog is bad but believe me, it gets worse in other wards/hospitals.

Not only do I agree with most of the comments left before me, but I also feel greatly attentive to what everyone here is expressing in their comments. Some of you I can say that I truly am able to relate to you, and some just make me wonder if I can ever relate to the way lots of you feel! In some ways it could be happy but if the feeling isn't really in the happiness stage of things then all I can say is I hope the becoming aware part of things does eventually work out for all of us in the end of things.. But alongside this topic, I love it! And it really is great to see a lot of us participating and really putting effort into collaborating one of the best blogs we've yet come to see!

Just wait, UCL, until you hit the medical gero wards. Surgery is supposed to be much better. Our critical care units are spot on. What I am hearing from friends who are nursing on general surgery wards is not good.

That was a fascinating read. A whole 15-20 minutes to bedbath a patient eh? Such luxury. On my ward I was told bluntly I must work faster because it should take me no longer than 10-15 minutes to bath or shower each of my patients including time taken collecting toiletries and clothes and escorting them to the bathroom and back!!! Perhaps we should use rollerblades to get us around the ward quicker. Perhaps we could strap the patients to giant skateboards to make it even faster! Now there's a thought.

PS Hope I never have to have surgery after watching a staff nurse larking about play-fighting rolling on the floor in her uniform and then going to tend a patient just back from an operation. This only happened the once so far as I know but it should not have happened at all.

In an atmosphere if universal deceit telling the truth is a revolutionary act. George Orwell.

Why has Nursing Care Deteriorated

Good nurses are failing every day to provide their patients with a decent standard of care. You want to know what has happened? Read this book and understand that similiar things have happened in the UK. Similiar causes, similiar consequences. And remember this. The failings in care have nothing to do with educated nurses or nurses who don't care. We need more well educated nurses on the wards rather than intentional short staffing by management.

About Me

I am a university educated registered nurse. We had a hell of a lot of hands on practice as well as our academic courses. The only people who say that you don't need a brain or an education to be an RN are the people who do not have any direct experience of nursing in acute care on today's wards. I have yet to meet a nurse who thinks that she is above providing basic care. I work with nurses who are completely unable to provide basic care due to ward conditions.
I have lived and worked in 3 countries and have seen more similarities than differences. I have been a qualified nurse for nearly 15 years. I never used to use foul language until working on the wards got to me. It's a mess everywhere, not just the NHS.
Hospital management is slashing the numbers of staff on the ward whilst filling us up with more patients than we can handle... patients who are increasingly frail. After an 8-14 hour shift without stopping once we have still barely scratched the surface of being able to do what we need to do for our patients.

Quotes of Interest. Education of Nurses.

Hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. Our findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients."...Journal of advanced nursing 2007

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level.

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania's Center for Health Outcomes and Policy Research found that patients experienced significantly lower mortality and failure to rescue rates in hospitals where more highly educated nurses are providing direct patient care.

Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report When Care Becomes a Burden released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 - one by the state of New York and one by the state of Texas - clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level.

Registered Nurse Staffing Ratios

International Council of Nurses Fact Sheet:

In a given unit the optimal workload for a registered nurse was four patients. Increasing the workload to 6 resulted in patients being 14% more likely to die within 30 days of admission.

A workload of 8 patients versus 4 was associated with a 31% increase in mortality. (In the NHS RN's each have anywhere from 10-35 patients per RN. It doesn't need to be this way..Anne)

Registered Nurses in NHS hospitals usually have between 10 and 30+ patients each on general wards.

Earlier in the year, the New England Journal of Medicine published results from another study of similar genre reported by a different group of nurse researchers. In that paper, Needleman et al3 examined whether different levels of nurse staffing are related to a patient’s risk of developing complications or of dying. Data from more than 5 million medical patient discharges and more than 1.1 million surgical patient discharges from 799 hospitals in 11 different states revealed that patients receiving more care from RNs (compared to licensed practical nurses and nurses’ aides) and those receiving the most hours of care per day from RNs experienced fewer complications and lower mortality rates than those who received more of their care from licensed practical nurses and/or aides. Specifically for medical patients, those who received more hours per day of care from an RN and/or those who had a greater proportions of their care provided by RNs experienced statistically significant shorter length of stay and lower complication rates (urinary tract infections, gastrointestinal bleeding, pneumonia, cardiac arrest, or shock), as well as fewer deaths from these and other (sepsis, deep vein thrombosis) complications

•Lower levels of hospital registered nurse staffing are associated with more adverse outcomes such as Pneumonia, pressure sores and death.
•Patients have higher acuity, yet the skill levels of the nursing staff have declined as hospitals replace RN's with untrained carers.
•Higher acuity patients and the added responsibilities that come with them increase the registered nurse workload.
•Avoidable adverse outcomes such as pneumonia can raise treatment costs by up to $28,000.
•Hiring more RNs does not decrease profits. (Hospital bosses don't understand this. They think that they will save money by shedding real nurses in favour of carers and assistants. The damage done to the patients as a result of this costs more moneyi.e expensive deaths, complications,and lawsuits, and complaints....Anne)

Disclaimer

I know I swear too much. I am truly very sorry if you are offended. Please do not visit my blog if foul language upsets you. I want to help people. That is why I started this blog and that is why I became a Nurse. I won't run away from Nursing just yet. I want to stick around and make things better. I don't want the nurses caring for me when I am sick working in the same conditions that I am. Of course this is all just a figmant of my imagination anyway and I am not even in this reality. Or am I?Any opinions expressed in my posts are mine and mine alone and do not represent the viewpoint of the NHS, the RCN, God, or anyone else.